Pain

At a recent visit with a patient I was reminded about the pain we do not always recognize. Physical pain has its own pain scale and gradation from smiley, to sad face; but what about the other pain we do not always inquire about? The emotional pain when our bodies and futures are threatened and change. Amputation, stroke, creeping dementia, advanced cancer engender fear. Fear is a form of pain not assuaged by a painkiller.

Pain of loss of function, pain of spiritual abandonment and many variations on these themes all add to the burden of illness.

Disease that interferes with communication, and fluency of thought and speech can be isolating and dehumanizing. Inability to communicate this loss of communication adds to the fear, paranoia even and anger of this personal and social excommunication.

I was privileged to see some of his drawings. Sometimes listening takes a little more time. Sometimes understanding requires the use of all of our senses.

+ psychology... flow... mindfulness...

What makes an individual happy? The roots of the psychology investigating what is right with ourselves rather than what is wrong probably starts with Maslow. His "triangle" reflects his theory of an hierarchy of needs and his book Personality and Motivation is a landmark in the field of motivation.

Relevance?

A patient forwarded a reference to an article in JAMA dealing with physician burnout and its negative effects on their satisfaction and patient relationships.

Reflecting on its findings raised a number of random thoughts . How do medical schools choose and train prospective doctors? How do doctors maintain their balance? How do patients with chronic illness deal with "disease and its management" burnout?

At a personal level my tools are provided by Maslow, Snyder, Victor Frankl, Mihaly Csikszentmihalyi, my family and my parents.

What attributes play into "survivorship" of both the provider and the recipient of health care? For the patient, survivor characteristics include resiliency, self actualization, strong social relationships, appropriate goal setting and willpower to quote some of the above. Charles Snyder was a positive psychologist who wrote "The Psychology of Hope" in which he discusses the better outcomes in "high hopeful" individuals.

Mindfullness I believe is part of a broader positive psychology theory of a Meaningful Life in which a positive sense of well-being, meaning, and purpose derives from contributing to the greater good of others.

In the JAMA article the surgeon indicates the positive experience immersion in an operation generates. He is experiencing what Mihaly Csikszentmihalyi has called Flow ... you may find this link to a 19 minute video interesting.

For the patient and their loved ones illness interrupts and threatens not only the daily activities of life, but at times life itself. Where to find the hope, motivation and will power?

I have left this blog incomplete and with a ? not an answer. More later?

DUU does not have to be duh?..

Decision making under uncertainty [ DUU ] .. I am reading Sharon Mcgrayne's history of Bayes' rule and game theory works by Steven Brams .... both have application to my practice....

More to come as I develop this theme.

[ I define "duh" rather narrowly as expressing incomprehension. If interested in "duh" you can explore further here.]

You cannot live forever....

What a busy week in the medical news: for chronic lymphatic leukemia patients a wonderfully scientific article using a virus [ neutered to prevent replication ] and further biological engineered, using gene transfer techniques, to create an expanding clone of immune competent cells to kill the leukemia cell. An iconic scientific study.

In contrast, this piece by a blogger in a recent The New York Times piece headlined "Trying to Live Forever", discussed observational medical studies and referenced a Consumer Reports Health article indicating the scientific weakness of observational studies. So far so good. He points out that the news media bombards their readers with "constant updates on the latest observational studies" which he considers counterproductive. I could not agree more.

The next element in his piece however gave me food for thought and a contrary view. Agreed we are all going to die and how is always an unknown event. Agreed that following common sense as regards nutrition, and avoidance of smoking is to our advantage, however dismissing gaining years by reducing risk of heart attack and the like because I may die ten years later of dementia does not resonate with my experience, logic nor philosophy.

The argument does not accommodate the wonderful quality of life that can be enjoyed in that ten years. An opportunity cost to say the least if I forgo my colonoscopy at 70 and as a consequence miss a colon polyp the removal of which has prevented a cancer growing and become incurable? Actuarial statistics/life tables indicates that at the age of 60 I can expect 20.92 years of life and a women 23.97 years! Dying of pneumococcal pneumonia because I did not have my vaccination at 70 for example would cheat me of

13.73 years.

How do I maximize quality of my remaining years to ensure that "gain" is pleasurable. Thats easy. Recognize the factors that are in your control and manage them. Start by reviewing the self help section of cancer-management.com.

The alternative is to be like Raymond in the movie Rain Man: paralysis by analysis.

What did those three patients with chronic lymphatic leukemia think?

What do you think?

Heroes and superheroes

Its been a while.

Thumbing through "The Psychology of Superheroes" took me back to a thread that has run through the interactions I have had with patients over the 40+ years I have been in clinical practice. The authors, proponents of Positive Psychology, note the absence of heroes in contemporary life and suggest current journalism exposing our sports, political and other glitterati as having clay feet. The authors review the character strengths, socialization and happiness factors reflected in the representation of superhero life.

So what has this to do with my day? I meet heroes every day. They live among us. No

costumes or outwardly obvious superpowers of flight or fight. They have the internal powers that make them strong and resilient. They have rewarding family and social interactions - they are fact, not fiction. They have no secret identity.

They are people which disease has made patients. An acute event such as leukemia or cancer has ambushed them and their families and brought out the character strengths they may not have realized was in them. Strengths that are required for survival.

Strengths that accompany patients on their final journey with grace, dignity and a lesson for the rest of us. I remember and salute you.

Inflammatory stuff......

Reviewing subject material for a talk to laypersons I am giving next month has added to my conviction that we can do more to help ourselves and rely less on the health care industry.

As you will see from my companion website I have a management "map" that incorporates the patient [ and family ] as strategic and executive partners in their own care.

The lifestyle component is the center of my talk and the subject for this post. Biologic evidence links inflammatory mediators, as one of many pathways, to cancer promotion and progression one cancerogenesis has been initiated. Inflammation is mediated by chemical messengers and cross-talk substances such as cytokines.

Some of this chemistry is pro-inflammatory; others anti-inflammatory. The question being what can we do to tip the balance to the healthy, "anti-cancer" direction? Our habits and environment can influence disease outcomes and quality of treatment.

1 Moderate exercise you enjoy.

2 Move to a "Mediterranean" diet.

3 Manage attitude and relationships - understand and use bio-behavioral skills.

4 Sleep and relax well by strengthening your coping skills.

How good...........?

Rabbi Kushner has written a number of books I can recommend. The one I was recently reminded of was "How Good Do We Have To Be? Although ostensibly addressing guilt and forgiveness it is has served as a useful personal theme for me as a doctor as I ask myself if I am maintaining my "goodness".

I have a personal "quality model" I test and calibrate myself against:

A] Is my knowledge base as a physician up to date?

B] Is my interaction with the patient sitting in front of me focussed?

C] Am I communicating and adequately transferring information?

Maintaining knowledge currency is easy in our web-enabled world. Push technology sends daily e-mail summaries of medical journals I have subscribed to for content summaries. Data aggregators send daily disease orientated e mail summaries and links. Selecting articles of incremental, practical and clinical value, hospital medical librarians then send a .pdf full article back for review and filing in a data base for future reference. These are often useful patient education material.

Entering a room to meet with a patient is entering a vacuum with suspended time. I must be fresh, not interrupted and concentrating on the only patient I have - the one sitting in front of me! Not easy in the health care industry 2010 style: interruptions from cell phones, pagers, colleagues. The economics of re-imbursement that drives doctors to see more patients in less time, use "physician extenders" such as nurses, nurse practitioners and physician assistants. Less face time, less talk, less explanation, more potential for errors or missed cues that may help diagnosis or management. It takes discipline and office practice rules and efficiency.

The third rule follows the above creation of uninterrupted time. I use sketches to map out the information I believe the patient requires to participate in management decision making and understand the basis for my recommendations. I encourage family to be present and our discussions recorded. I publish my home e-mail address on my "business" card to encourage communication, questioning and dialogue.

Concentration, communication and clarity.